Download audit of imaging request forms at the university of nairobi dental

The chairman
KNH/UON Ethics, Research and Standards Committee
Kenyatta National Hospital
rd
23 August, 2012
Through,
External Supervisor,
DR. EUNICEKIHARA
Dear Sir/Madam
RE: RE-SUBMISSION FOR ETHICAL REVIEW
I hereby wish to re- submit my proposal for a study on "Audit of imaging request forms at the university
of Nairobi Dental Hospital" for ethical review.
I have made the suggested corrections.
The research project proposal is submitted in Partial fulfillment
of the requirements
leading to a Bachelor of Dental Surgery degree from the University of Nairobi, 2012.
Yours sincerely,
..~
.
KIMUTAIBARSANG
for the award
AUDIT OF IMAGING REQUEST FORMS AT THE UNIVERSITY OF
NAIROBI DENTAL HOSPITAL, UNDH
INVESTIGATOR: KIMUTAI
BARSANG-B.D.S III
V28/2726/2009
A
RESEARCH
PROPOSAL
SUBMITTED
IN
PARTIAL
FULFILLMENT
OF
THE
REQUIREMENTS FOR THE AWARD OF THE BACHELOR OF DENTAL SURGERY OF THE
UNIVERSITY OF NAIROBI -2012
DECLARATION
I, Kimutai Barsang, a third year BDS student at the University of Nairobi, declare that this is my
original work and has not been submitted elsewhere for the award of any degree or for any other
purpose.
Signed
~
Date
?~/~!!.'>::"
ii
.
APPROVAL
I, Kimutai Barsang, is submitting this proposal to the Research, Ethics and Standards Committee,
Kenyatta National Hospital (KNH) and university of Nairobi (UON).
This proposal has been submitted with approval of my supervisors;
DR.REGINA MUTA VE, BDS (NBI), MRes (St. Andrews)
Department of Periodontology, Community and Preventive Dentistry
University of Nairobi
Signed
~.~.l..~l~.l.~
Date
~.~
DR.EUNICE KIHARA, BD.S (NEI)
Department of Oral and Maxillofacial Surgery
University of Nairobi
Signed
~'
~.'.
\
Date
j)
Cl4 16\ t:L
iii
.
.
TABLE OF CONTENTS
TITLE
DECLARATION
,
APPROVAL... ...
TABLE OF CONTENTS
ABBREVIATION...
ABSTRACT
PAGE
11
111
IV
V
1
CHAPTER ONE
INTRODUCTION
LITERATURE REVIEW
PROBLEM STATEMENT
JUSTIFICATION OF THE STUDY.
OBJECTIVES
HYPOTIffiSIS
VARIABLES
2
5
7
7
7
8
8
,
CHAPTER TWO
MATERIALS AND METHODS
STUDY AREA
STUDY POPULATION
STUDY DESIGN
SAMPLING METHOD
SAMPLE SIZE
'"
INCLUSION CRITERIA
EXCLUSION CRITERIA
DATA COLLECTION METHOD
DATA ANALYSIS AND PRESENTATION
ETHICAL CONSIDERATIONS
BENEFITS OF THE STUDY.
'" .. ,
'"
CHAPTER THREE
REFERENCES
APPENDIX 1(DATA COLLECTION SHEET)
APPENDIX 1(IMAGING REQUEST FORM)
9
9
9
9
9
9
10
10
10
10
11
11
12
13
14
iv
ABBREVIA TIONS
B.D.S
-Bachelor of Dental Surgery
UON
-University of Nairobi
MRes
-Masters in Research
UNDH -University of Nairobi Dental Hospital
LMP
-Last Menstrual Period
v
ABSTRACT
Background: Imaging request forms are essential communication tools used by doctors referring
patients for radiological investigations. Therefore, filling the request forms adequately and in details is
paramount in making concise radiological diagnosis.
Objective: To carry out an audit on completion of imaging request forms currently in use at the
UNDH
Study design: A retrospective descriptive study will be used to assess the compliance of referring
clinicians in adequate completion of the imaging request forms.
Setting: The study will be conducted at the university of Nairobi Dental Hospital
Data collection method: Imaging request Forms will be accessed and assessed after processing at the
booking desk. Each form will be assessed for completeness of the fields.
Study benefits: The study results will be used to sensitize clinicians on the importance of complete
filling of imaging request forms and will assist in partial fulfillment of requirements for the award of
Bachelor of Dental Surgery in the University of Nairobi.
1
CHAPTER ONE
INTRODUCTION
Imaging is the technique and process used to create images of parts or whole of human body for
clinical purpose like seeking to reveal, diagnose or examine disease.
Imaging request form is a specially designed form filled by clinicians before imaging is done.
Imaging is widely used in the medical field. In dentistry, it is one of the major diagnostic aids. For
example, it is used to show presence of pathologies like caries, cysts and tumors, show the state of
restorations, monitor disease progression, detect fractures, monitor progress of treatment, localize
foreign bodies, gross examination of maxilla and mandible, examine the degree of bone loss or even to
localize impacted, unerrupted or supernumerary teeth'.
The decision to carry out any investigation should be based on: correct assessment of the indications,
the total expected yield, the way in which the results are likely to influence diagnosis and the clinician
having adequate knowledge of the physical and biological properties
of ionizing radiation. The
patients should also have a full understanding of the risks involved and give their consent.
In addition, a framework of written procedures should be provided and should include information on;
patient identification,
clinical
summary,
exposure
justification,
identification
of referrers
and
identification of pregnant patients. All these details are contained in imaging request forms.
At UNDH, various radiographic examinations are performed which include intraoral and extraoral
radiographs.
These comprise;
bilateral
bitewings,
intraoral
periapical
views,
occlusal
views,
orthopanthomogram (OPG), cephalometry, skull projections and siologram. They are all indicated for
different conditions.
These are requested using imaging request forms which contain the following fields; name of patient,
age, gender, file, number, and last menstrual period, previous history of x-rays clinical summary and
signature of approval (appendix
1) .Forms filled by students
supervising tutor.
2
require to be countersigned
by
All these details are critical in the management of the patient.
They also form part of the selection
criteria that is used to justify radiographic examination. Therefore, filling the request form adequately
and in details is paramount in making concise radiological diagnosis. Thus, filling of the request forms
adequately cannot be overemphasized as it reduces the number of unhelpful radiographic examinations
and aids concise radiological diagnosis.
For example, the clinician has to include the biographic data because it is important for patient
identification and for future reference. Failure to include the name makes the image invalid. This may
lead to confusion during processing and increase chances of delivery to a wrong patient. It may result
in wrong diagnosis and hence wrong treatment planning. It may also interfere with future referencing.
Age is also helpful for patient identification, in choosing appropriate radiographic exposure parameter
and in predicting the risks of ionizing radiation on the body of the patient. X-rays are known to cause
biologically damaging effects on the body notably cancer. A broad estimate of the magnitude of the
risk of developing a fatal radiation induced cancer from various x ray examination was published in
1999 by National Radiation protection board in the United Kingdom in their booklet "Guidelines on
Patient Dose to Promote Optimization of Protection for Diagnostic Medical Exposures", This showed
that the risk is age- dependent being highest for the young and lowest for the elderly. Children are
actively growing and may interfere with such growth. 2
Last menstrual period may help predict whether the female patient is pregnant or not. This information
is important since it will help the radiographer to protect the patient during exposure.
3
History of previous imaging is vital since it reveals the number of previous exposures. It also helps
avoid unnecessary
repetition of a recently done examination
condition has changed or not
3 . Thus
and in demonstrating
whether the
patients are encouraged to come with images that have been done
elsewhere.
Clinical summary include Signs and symptoms found in the patient history or clinical examination that
suggest that a radiographic examination will be useful.it is also important in helping the clinician make
an appropriate diagnosis by relating the radiological findings to the clinical summary. It also provides
useful information to the radiographer that may help in appropriate positioning of the patient so as to
capture targeted structures. From the clinical summary the radiologist
clinician on the best investigation to undertake".
3
will be able to advise the
The signature of approval is important as it acts as a confirmation that the details that have been filled
appropriately to enhance proper management of the patient and may also be used for medical-legal
reasons.
Different hospitals have personalized designs of imaging request forms depending on the data they
require. For example, some may include patient's phone number, postal address, referring clinic and
history of any previous surgery. They give biographic and clinical information of the patient.
Therefore, the aim of my project is to determine whether all the details in the imaging request forms
currently in use in UNDH are filled based on the critical role they play in the holistic management of
the patient and in reducing risks like misdiagnosis.
4
LITERATURE REVIEW
There has been no audit of x-ray request forms in the University of Nairobi in the recent past.
Studies have been done to assess the level of completion of imaging request forms and some studies
have shown that up to 20% of radiographic exam are clinically unhelpful because they were wrong or
not appropriate from the beginning especially during placement of request. Thus filling of request
forms adequately and in details is paramount in helping the radiologist give less clinically unhelpful
radiographic exam and concise radiological diagnosis.(Akinola et al 2010)4
Some studies have also revealed that all fields in imaging request forms are incompletely filled. For
example, a study on radiological request forms in Lagos State University Teaching Hospital, Lagos
Nigeria where 144 requests were audited showed that all forms were incompletely filled. Almost all
had names of patients filled except 2(1.4%) where column for other names were not filled. Only
130(90.3%) had their ages filled through and 74(57%) did not indicate unit of measurement in terms of
years, months or days. Out of the 6(4.2%) addresses filled, only 3 were fully filled while 138(95.8%)
addresses were not filled at all. (Depasquale et al 2005i
Some studies have also revealed existence of important omissions and poor compliance in filling of
important requested data by referring clinicians. For example, an audit assessing local practice in St
Luke's Hospital Malta in 2004 revealed that only 4% of 200 request forms reviewed were completely
filled. Percentages
of different fields filled were; patient's
name
100%,full
29%,referring ward 95%,referring doctor's signature 100%,referring doctor's
address
77%,age
name and surname
34%. These were thus incomplete and unable to fulfill their purpose. (Agwu et al 2005)6
In an audit of radiological request forms at the university of Nigeria Teaching Hospital, Enugu, noncompliances were noted in the column of patients age and sex that though provided had no
information supplied by clinician in 42% [n=3570] of the cases, parts of the body to be examined was
not stated in 40% [n=3400] and the dates the request were not indicated in 30% [n=2550] (Oswal et al
2008)7
5
The results of the audit done by Oswal et al (2008) on adequacy of completion
forms
request
011
(RRF) in Radiology
Academy, Leeds showed a number of inadequacies
forms. It was noted that this could have medical-legal
implications
studies have also shown that a well-designed
information,
radiological
request
necessary for provision of good and reliable radiological
6
in completing
the
et al 1990)8
form will provide
increase compliance of clinicians in completing the forms(Philips
better assessment
requests
and serious consequences
the quality of the overall service provided by radiology departments.(Scott
Some
of radiology
more
et al 1990)9 and enable
services (Chang
1988)]0
CHAPTER TWO
STATEMENT OF RESEARCHPROBLEM
Radiological request forms are essential communication tools used by doctors referring patients for
radiological investigations. However, its importance is often undermined making the radiographic
examinations clinically unhelpful because they were either not properly filled or the request was
wrong from the beginning. Filling of the request form adequately and in details is therefore paramount
in making concise radiological diagnosis.
JUSTIFICATION OF THE STUDY
Inadequate filling of radiological request forms is a worldwide problem and no audit has so far been
done in the UNDH. The audit is thus aimed at determining the level of compliance in completion of xray request forms currently in use in this tertiary institution basing on the critical role played by each
of the required data on the request form.
STUDY OBJECTIVES
General
-To carry out an audit on completion of imaging request forms currently in use at the UNDH
Specific
-To determine the level of completion of personal data in the imaging request form
-To determine the level of completion of the clinical summary of the patient
-To determine whether approvals for the requests are provided
7
HYPOTHESIS
All the required data on the imaging request form is completely provided in the request forms.
VARIABLES
Socio-demographic variables
Personal information -age
-gender
Independent variables
-date
-type of investigation
-clinical summary
-name of the lecturer and signature
-previous X-ray exposure
Dependent variable
-completeness of imaging request form
8
CHAPTER THREE
MATERIALS AND METHODS
STUDY AREA
The study will be conducted at the university of Nairobi Dental Hospital
STUD Y POPULATION
The study covers request forms in patients' files at the UNDH Registry
STUDY DESIGN
It is a retrospective descriptive study designed to measure the compliance of referring clinicians in
adequate completion of the imaging request forms.
SAMPLING METHOD AND SAMPLE SIZE
The sampling unit will consist of imaging request forms of cases seen in UNDH from January 2010 to
December selected using simple random sampling.
A study done by Akinola et al in 2010 showed that 20% of radiology request forms were incompletely
filled.Using this as prevalence and a confidence level of 95%,a sample size of
follows:
Sample size (n) = Z2p(1_p)
C2
Z =Z value (1.96)
P=Prevalence (20%)
C=l-confidence level (1-0.95)
Therefore n=1.962xO.2xO.8
(0.05f
=246
9
was calculated as
INCLUSION CRITERIA
-Any image request form for images taken in UNDH
EXCLUSION CRITERIA
-Any image request form not filled in UNDH
-patient files that do not have image request forms
DATA COLLECTION METHOD
Forms will be accessed and assessed after processing at the booking desk. Each form will be assessed
for completeness of the fields. A field is taken completed when something is written in the field. This
is done to remove any subjective bias regarding appropriateness of what was written. A blank field
will be assigned
a 0 (zero) score while a completed field will be assigned a score of 1(one ).Eleven
fields will be assessed in each form. Thus each form will have a maximum score of 11. The data will
be entered in a data collection sheet-(Appendix
1)
where the first image that was done within the
study duration will be assigned number 1
DATA ANALYSIS AND PRESENTATION
Each completed request form will be entered as a new record and all the data will be collected and
analyzed using the statistical package for social science (SPSS version 12.0) for windows
The measures
to be computed in percentages and the information presented in form of graphs, tables
and pie charts.
Data cleaning will be done by running frequencies and all missing data counter-checked and corrected
where necessary from the original form to improve the validity of the results.
10
ETHICAL CONSIDERA TraNS
Approval will be obtained from the Kenyatta National Hospital and the University of Nairobi Ethics,
Research and Standards Committee and a copy given to the UNDH central records registry to facilitate
perusal of patients' files in strict confidentiality within the records department. All patients'
records
will be reviewed in strict confidentiality within the institutions and promptly returned to the records
clerks for filing to prevent their loss.
BENEFITS OF THE STUDY
-The study results will be used to sensitize clinicians on the importance of complete filling of imaging
request forms
-This project will assist in partial fulfillment of requirements for the award of Bachelor of Dental
Surgery in the University of Nairobi
11
CHAPTER FOUR
REFERENCES
1. Erick Whaites; Essentials of Dental Radiography and Radiology textbook, third edition, pages
29-31
2. White SC, Pharoah MJ, Editors Oral Radiology: Principles
and Interpretation.S'"
edition,
Mosby Company, St.Louis 2004
3. Dhingsa R, Finlay BL, Robinson GD, Lidolicoat AJ; Assessment
of agreement
between
General Practitioners and radiologists as to whether radiation exposure is justified, British
Journal of Radiology;2002;7S(870); 136-239
4. Akinola R.A, Akinkumna M,Wrign
KO, Orogbemi 0; Radiology request forms; are they
adequately filled by clinicians? Internet Journal of Radiology 2010, volume 12 number 1
S. Depasquale R, Crock Ford; Are radiology requests completely filled in? An audit to assess
local practices; Malta Medical Journal 200S
6. Agwu K.K, Okoye 1.J ; Audit of radiological request forms at university of Nigeria teaching
hospital, Nig.of IHosp.Med volume 15(2) April-June 2005
7. Oswal D, Sapherson D,Rebman A; A study of adequacy in completion of radiological request
forms, June 2008 at Radiology Academy, Leeds, United Kingdom
8. Philips WC, Scott JA; Medical decision making; Practical points for practicing Radiologist,
AJR 1990; 154; 1149-S5
9. Chang PJ; Bayesian Analysis Revisited; A Radiologist Survival Guide AJR 1988; 152; 721-7
12
APPENDIX 1: DATA COLLECTION SHEET
Name
Date
Gender
Age
LMP
File no.
Type of
investigation
Previous
x-rays
Clinical
summary
Approval
student
13
degree of
completion
Tutor
APPENDIX 2: IMAGING REQUEST FORM
UNIVERSITY
OF NAIROBI
F ACUL TY OF DENTAL
X-RAY
REQUEST
NAME •....•................•..•..•........•...••.•.•......•..•...••••.•....
AGE .........•.•....
SEX ..•..••.•.......
SCIENCES
FORM
DATE ..•....•....•....••.......•....
LMP •..•........•.•..
NUMBER ....•....•...•..
ANYPRE~oUSX-RAYS
_
TYPE OF INVESTIGAnON
CLINICAL SUMMARY
STUDENT'S NAME
SIGNATURE,
DOCTOR'S NAME
SIGNATURE
14
_
_